Submit an Order

Patient Demographics

Please attach a copy of the patient demographics, front and back of insurance card, complete medication list, clinical notes and date of routine EEG.
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    Clinical History

    Medically Necessary Diagnosis Codes(Required)


    Previous (if applicable, check all that apply)
    If no previous REEG is listed above OR one is listed and the results are not provided, I understand a Routine EEG will be performed prior to the 72-HR AEEG and, under those circumstances, I am specifically ordering the Routine EEG to be performed prior to the Ambulatory EEG. *Please provide results for previous test(s).

    Ordering Healthcare Provider

    Healthcare Provider Statement: I certify that I am referring the above-named patient for electroencephalographic (EEG) monitoring (routine EEG, 72-HR ambulatory EEG with video) as listed above, and to the best of my knowledge this test is medically necessary in order to diagnose the patient. I understand that the diagnostic testing provided will not itself provide a diagnosis nor will it recommend a therapeutic treatment for this patient.